Lehmann and Ban’s Pharmacotherapy of Tension and Anxiety

INFORMATION ON CONTENTS: Pharmacotherapy of Tension and Anxiety is divided into seven chapters, including Introduction and Conclusions. It opens with an exposition of the “clinical and conceptual uncertainties” about anxiety and its pharmacological treatment. The first paragraph of the Introduction reads: “Americans are now spending over $500 million each year for sedative drugs --commonly called tranquilizers-- to combat a wide variety of conditions gathered loosely together under the name of anxiety. Virtually all of this money is spent on doctor’s prescriptions; one out of ten prescriptions is for this type of drugs. This is despite the fact that the very conditions for which the drugs are being ordered are still often poorly understood by the clinicians, that they defy still a widely acceptable scientific definition, and despite the fact that there still is no general agreement as to the mechanism of action of tranquilizers or even their clinical effectiveness”. The introduction (Chapter I) continues with the definition of ”anxiolytic sedatives”; the tracking of the term “tranquilizer” to 1822; the definition of the term “anxiety” from existential, clinical and experimental standpoints; and the differentiation of “anxiety” from stress, tension, arousal, excitement and depression.

In Chapter II, the different “types of drugs” used in the past and present to control anxiety, psychomotor restlessness and insomnia introduced during the second part of the 19th century, are reviewed, including the bromides, chloral hydrate and paraldehyde; and the barbiturates, propanediols, benzodiazepines, carbinols, piperidinediones, quinazolonesand dipenylmethanes, brought into clinical use, subsequently, in the first seven decades of the 20th century. The information on barbiturates, popanediols and benzodiazepines, the three groups of drugs that dominated prescribing for anxiety,in this order chronologically, includes details about their chemical structure; absorption, metabolism and excretion; neurochemistry and neurophysiology; behavioral pharmacology; and adverse effects, including toxicity and dependence.

In Chapters III and IV, the common and differential “behavioral effects” (Chapter III) of anxiolytic sedatives, as well as their “interaction with conditioning“(Chapter IV) are discussed. Special attention is paid to their effect on perceptual, cognitive and psychomotor performance in humans, and to their property of increasing conflict tolerance in both, animal and human experiments.

In Chapter V, the “possible mechanism of action” of anxiolytic sedatives is entertained. It is suggested that traditional sedatives, like the barbiturates, inhibit the entire feedback network that plays a role in anxiety, i.e., the reticular activating system (RAS), the limbic lobe and the neocortex, whereas the newer anxiolytic sedatives, like propanediols and benzodiazepines have less inhibitory effect on the RAS and neocortex than on limbic structures. In so far as biochemical changes are concerned, mostanxiolytic sedatives either decrease catecholamines or antagonize their effects: meprobamate decreases catecholamine excretion, chlordiazepoxide blocks stress-provoked rise of catecholamines, diazepam antagonizes the central stimulant effect of noradrenaline, and barbiturates lower both noradrenaline and adrenaline excretion in humans. Furthermore, bothchlordiazepoxide and diazepam, suppress the somatotrophic hormone, while increase the output of 7-ketosteroids.

The book culminates in Chapter VI, in which “clinical applications” of anxiolytic sedatives are discussed with consideration of some “general principles” about their use. This is followed by identification of their “general indications”, that includes anxiety, a subjectively distressing symptom, somatic (autonomic) and behavioral manifestations of tension states, behavioral excitement and insomnia, perceived as a functional disorder of a biological rhythm. The chapter also includes information on “specific indications” for some of the anxiolytic sedative drugs; findings in “comparative studies” with anxiolytic sedatives; and a discussion of their “limitations and dangers”, such as “suicide”, “dependence and withdrawal” and“effects on driving”.

In the final, concluding chapter (chapter VII), characteristics that the authors believe would be an ideal anxiolytic sedative are described, and some leads for developing new anxiolytic sedatives drugs are entertained. One such lead is the finding that the spinal fluid of sleeping animals contains an unidentified substance that induces sleep when transfused into other animals.

The book is complemented with a Bibliography, a Compendium of Anxiolytic Sedatives and an Author and Subject Index.

REVIEWER’S STATEMENT: At the time Pharmacotherapy of Tension and Anxiety was written, benzodiazepines dominated prescription practices for anxiety and tension in the United States. Originally prepared for a chapter in a multi-authored text, Pharmacotherapy of Tension and Anxiety, found its place in W. Horsley Gantt’s series on American Lectures in Objective Psychiatry.